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桥接Covid-19的种族鸿沟

经过Amanda Brimmer,Marin Gjaja,Dan Kahn,Bryann DaSilva,Kedra Newsom Reeves, and玛丽莎·格拉(Marisa Gerla)

Against a backdrop of protests and a national conversation about systemic racism, disproportionate numbers of Black and Hispanic people in the US are dying from COVID-19. The prevailing view is that the higher number of deaths is due to three factors: underlying health conditions, the lack of access to quality health care, and exposure to the virus.

But our data analysis reveals that is not the case. Neither underlying health conditions nor the lack of access to quality health care has played a primary role in the discrepancy, though the latter was an issue early in the pandemic, when the lack of health insurance prevented many people from seeking treatment. Rather, the chief reasons for the disproportionate number of deaths are the greater risk of exposure to people with COVID-19 and less access to COVID-19 testing. By our calculations, these reasons account for about 85% of the disparity. Underlying health conditions, age, and the lack of access to quality health care account for the remaining 15%. (See Exhibit 1.)

The widespread misinterpretation of the data has had grave consequences. In particular, it has distracted policymakers from the immediate imperative to address the systemic racial disparities that are related to exposure as well as testing access. As a result, COVID-19 is again surging among people of color. Hispanic communities in the southern region of the US and in California are getting hit especially hard.

相比之下,芝加哥在与Covid-19的战斗中迈向医疗保健公平的旅程表明,可以而且应该做更多并且应该做更多的事情来保护有色人种社区。为了减少冠状病毒在有色人种中的传播,保护那些是必不可少的工人和高接触职业的人至关重要。扩大色彩社区的测试站点的数量并确保获得优质护理的持续机会也至关重要。

Coming to Grips with the Data

To get a true sense of the impact of the pandemic on the lives of people of color, we analyzed data on COVID-19-related deaths, infection fatality rates (IFRs), and infection rates for Black, Hispanic, Asian, and white people in the US. We then investigated the root causes for the disparities among the different groups. (See “About Our Research.”)

关于Our Research

To get a better understanding of the impact that COVID-19 has had on people of color in the US, BCG analyzed data from the US Census Bureau and the Centers for Disease Control and Prevention (CDC), including data collected by the CDC’s Behavioral Risk Factor Surveillance System (BRFSS).

Synthesizing various analyses and expert interviews, we determined the expected Infection Fatality Ratio (IFR) by age group and by the presence or absence of a relevant underlying health condition. We then applied these rates to demographic data from the US Census and the BRFSS for each racial group by state to determine the expected IFRs by group, adjusted for age and underlying health conditions.

Using these expected IFRs and reported deaths, we estimated the number and rate of infections for each racial group. The number of infections is calculated by dividing the actual number of deaths by the expected IFR.

It was also possible to estimate the root causes of the death difference between people of color and white people. We compared the infection rate for each racial group with the distribution of deaths reported through June 24, 2020, to find the portion that can be explained by age and underlying health conditions. When we repeated this analysis with data reported through July 15, 2020, the results were nearly identical, so this is likely to be a sustained trend.

Subsequent to our demographic analysis, we methodically evaluated various root causes in sequence to determine which ones were most important: underlying health conditions and age, the lack of access to quality health care, or greater risk of exposure to COVID-19 and less access to testing.

死亡人数。数据很清醒。对于18至65岁的美国人口,尽管仅占该人口的14%,但黑人占所有共同死亡人数的32%。(请参阅图表2。)当我们比较每组年龄18至65岁的每10万人的共同死亡人数时,我们发现黑人死亡人数比白人高5.8倍西班牙裔死亡人数是白人的4.2倍。

Regional data yielded similar insights. Expectedly, the number of COVID-19 deaths for Black people and for white people varies significantly from state to state. But the number of COVID-19 deaths for Black people is higher than the average number for the general population in almost every state reporting this data. (See Exhibit 3.) In urban areas, the number of deaths for Black people is about 1.5 times higher; in rural areas, it is four times higher.

IFR.Epidemiologists define IFR as the percentage of people infected with the virus—regardless of whether they have been diagnosed—who are expected to die from it. In July, the World Health Organization stated that the current consensus global IFR for COVID-19 is .6%.

一个组的IFR主要取决于潜在的健康状况和年龄分布的患病率。我们估计,对于美国的黑人和西班牙裔人,IFR分别为0.4%和.3%,略低于白人的IFR(.5%)。对于亚洲人来说,它甚至更低(.2%)。老年白人的人口基础是该估计的大部分。

感染率。Given US testing limitations and the high prevalence of asymptomatic cases, we have to estimate the true infection rate. Estimated infection rates depend on IFRs and the reported number of deaths per racial group. By our calculations, the infection rates for Black and Hispanic people are respectively three and two times higher than they are for white people. (See Exhibit 4.) This is important because it shows that infection rates for people of color are the primary reason for disparities in COVID-19 outcomes.

The Key Factors Influencing Racial Disparities

Why are death and infection rates so much higher for people of color than they are for white people? There are four factors to consider: the greater risk of exposure, less access to testing, underlying health conditions and age, and the lack of access to quality health care.

Greater Risk of Exposure.Of the various factors that are linked to infection, exposure to the virus is the most important because people of color are at significantly greater risk of exposure for various reasons related to social determinants of health. They are, for example, significantly more likely to live in multigenerational housing, use public transit, and work in environments where they are more exposed to the virus.

虽然只有16%的白人生活在多代家庭中,但有色人种的人数高出60%至80%。近30%的亚洲人生活在多代住房中。除多代家庭外,冠状病毒还受到了冠状动脉袭击。迄今为止,有大量人口(超过25%)有色人种的疗养院中有60%的疗养院报告了COVID-19案件,而30%的疗养院人口少于人口(低于5%)颜色。监狱居民对冠状病毒的阳性测试是普通人群的五倍。

Working conditions are especially problematic. Black and Hispanic people make up a disproportionate share of two groups of workers that have the highest risk of exposure.

  • 重要的工人。The largest group that has a high risk of exposure is essential workers. This group spends many hours each day in places such as grocery stores, pharmacies, and hospitals. Essential workers make up approximately 33% of the overall workforce and 45% of the workforce that is people of color.
  • Workers in High-Contact Occupations.另一组是由具有高风险的工人组成的,因为他们与非常拥挤的工作场所(例如工厂和酒店)抗衡。这些环境中的工人是有色人种的不成比例。例如,有色人种占肉类包装行业中约60%的员工,但几乎占该行业确认的COVID案件的90%。

更少的测试访问。关于测试的数据反映了有色人种和白人之间的广泛差异。不平等是由于测试,访问测试和测试地点的要求,对测试的怀疑和单语言外展的要求。

  • Requirements for Testing.在大流行的早期,许多州都规定了进行测试的处方。这对许多没有私人医生的西班牙裔提出了挑战(有20%的人报告没有个人医生或医疗保健提供者,而白人约有5%)。但是,当许多州放松有关处方规则时,这个问题在很大程度上消失了。
  • Access to Tests and Testing Sites。平均而言,主要由有色人种组成的区域的邮政编码比大多数白人居民的邮政编码要少15%。此外,主要是有色人种的邮政编码中的人均测试数量仅比主要是白人的邮政编码中的数量高25%。如果管理测试的数量是基于感染率的,则主要是有色人种的邮政编码是测试数量的两到三倍,是主要由白人组成的邮政编码中的平均值。显然,没有足够的有色人种正在获得19号测试。为什么?我们认为有几个因素在起作用。有些雇主要求,一些收入低的人在等待结果时无力休假。此外,最近的研究表明,与大多数白人居民的社区相比,有色人种面临更长的等待时间,色彩社区的测试供应不足。在其他情况下,缺乏汽车的当地居民无法获得良好的努力,例如特拉华州的通行测试地点。 Regardless of the cause, however, the result is the same.
  • 对测试的怀疑。Some people have been reluctant to get tested because they mistrust the government. That may be because long-standing racial inequities in health care have made some people reluctant to give authorities access to their private data. The consequences of being tracked and traced may be especially worrisome for undocumented immigrants who are at risk of losing their jobs or, worse yet, deportation.
  • Monolingual Outreach。仅说西班牙语的西班牙裔人可能错过了测试,仅仅是因为外展主要是英语。鉴于美国约有20%的西班牙裔人不会说英语,因此错过了接受测试的机会的人数可能很重要。

潜在的健康状况和年龄。患有慢性健康状况的人,例如心脏病或糖尿病或65岁以上的人易受伤害的到19号。如果被感染,这些可养育的人会屈服于该疾病的高风险。由于黑人成年人的健康状况比白人成年人的比例更高(30%,比25%),因此通常认为潜在的条件是黑人人数更高的联盟-19死亡人数较高。(这不适用于西班牙裔,因为只有20%的人患有相关的慢性健康状况。)

That assumption is incorrect, however, because Black adults with underlying conditions are typically younger than white people with chronic conditions, largely offsetting the influence that such diseases have on the death rate. Approximately 25% of white people are over the age of 65, but only 16% and 9% of Black and Hispanic people, respectively, are over the age of 65. Overall, higher health vulnerability is not a significant cause of the higher number of deaths among people of color; by our estimate, it accounts for less than 5% of the difference.

无法获得优质的医疗保健。要考虑的最后一个因素是医疗保健访问,有三个关键驱动因素:

  • 医疗保健能力。我们的县级分析表明,总体而言,白人人口的县的医院病床数量相似,人均ICU容量与有有色人种的人相似。尽管某些地区存在物质差异,但不足以表明医疗保健能力在199号死亡差异中发挥了重要作用,即使这是有据可查的其他慢性健康结果差异的贡献者。
  • 健康保险。在大流行的早期,健康保险的覆盖范围很可能有限地获得医疗保健:在美国,黑人和西班牙裔人的百分比较高,没有保险,并且由于大量自付额外的范围可能没有寻求测试或治疗费用。但是,到4月下旬,当联邦计划和保险豁免开始支付COVID-19测试和治疗的自付费用时,这不再应该是一个问题。由于死亡率仍然存在很大的差异,因此我们可以排除健康保险为主要因素。
  • 护理质量。每100,000人的Covid-19住院的黑人和西班牙裔患者人数是白人患者相似的住院时间的四倍。但是,住院的白人比住院的有色人种(20%,比例为13%)。这表明,一个人在医院接受的护理质量不可能是有色人种死亡人数较高的主要原因,尽管这似乎是某些地方的一个因素。尽管如此,有色人种的住院数量明显更高。可能是由于许多黑人和西班牙裔人缺乏初级保健提供者或进入社区诊所的事实。(请参阅“芝加哥:一个很好的例子”。)

芝加哥: A Case in Point

芝加哥市提供了一个说明,说明了政府和社会如何共同努力解决医疗保健差异并取得更公平的成果。

Because it was collecting COVID-19 data by race, Chicago identified a wide disparity for the testing positivity rates between two groups: people of color and white people. In early April, the rate for white Chicagoans was 38%, but it was 23 and 36 percentage points higher for Black and Hispanic Chicagoans, respectively. (See the exhibit.)


因此,该市推出了公共卫生外展和教育运动的种族平等快速响应团队(RERRT),旨在制定建议,动员社区合作伙伴并确定为少数群体人口的社区提供优先资源。RERRT与当地领导人合作促进洗手,鼓励测试,并分发免费的口罩和洗手液。它还要求医院共享有关COVID-19患者的种族和种族数据。

自RERRT推出以来,黑人芝加哥人的测试阳性率与白人居民的速度几乎相同。西班牙裔芝加哥人的比率仍然约为10%,这表明某些有色人种的困难持续存在。RERRT在这些社区的工作正在进行中。

Policies for Addressing the Disparities

We believe that a robust set of actionable policies is a good starting point for addressing the enormous racial disparities around COVID-19 outcomes that exist in the US today. The following list of policies is by no means exhaustive—see our fuller set of保护脆弱的潜在政策。我们之所以提及这些,是因为它们与有色社区特别相关,并且可以大大降低其整体死亡率。

  • 分发口罩。Governments should dispense masks to all who are健康脆弱(and those who are close to them), who have a greater risk of exposure, and who suffer economic hardships. Additionally, officials should strongly encourage everyone to wear the masks. Distributing masks and enforcing that they are worn is the single most cost-effective tool that policymakers can use to fight the disease. But people of color, especially Black men, have reported harassment and a fear of being profiled if they wear a mask. Therefore, in areas with predominantly people of color, local officials should strongly encourage that people wear masks but may choose not to require it. Additional research should be done to assess the efficacy of face shields or other solutions as an alternative to masks.
  • 进行每周测试。Governments shouldtest people who have a high risk of exposure at work as well as those who are in close contact with people who are over the age of 65 or who have underlying health conditions. There are three important practices to observe. First, normalize the number of testing sites and tests across regions on the basis of test positivity rates (the number of people who tested positive divided by the number of people who were tested). Communities of color should have the same test positivity rates as communities with predominantly white people. Having more-accurate numbers will provide a clearer picture of how many more testing sites and tests are needed to ensure that people of color have adequate access to testing. Second, increase awareness of the importance of getting tested. Improving outreach and multilingual guidance are key. Third, for outreach and testing sites, partner with organizations that people trust, including community groups, churches, nongovernmental organizations, and public services. Testing sites should not require IDs for testing because it could inadvertently deter undocumented people.
  • Mitigate the risk of contracting the coronavirus in the workplace.政府应该建立、监控和执行strict occupational safety protections for people who work in environments where the risk of exposure is high. Penalizing noncompliance would improve working conditions in places (such as meat processing plants) where large numbers of people are at high risk. Governments can also provide funding for safety measures—such as N-95 masks, safe transportation options, and opportunities for health-vulnerable workers to be voluntarily deployed elsewhere—thereby incentivizing companies to implement them.
  • Limit the risk of spreading the coronavirus in high-risk residences.A tragic number of deaths have occurred inside congregate living facilities. Congregate living facilities must systematically implement regular testing for all residents and staff, strictly limit in-person visits, and establish safe quarantine options to apply in the event of a coronavirus outbreak.
  • Expand the number of community health centers.大约有2,000名由少数民族人口主要关闭的社区的联邦资助卫生诊所已暂时关闭,其中更多的永久性关闭边缘是其财务前景。至关重要的是要重新开放这些设施所需的步骤,并在可能的情况下扩大数字。被证明可以增加对医疗服务信任的政策措施也很重要。社区卫生工作者(CHW)是一个不错的起点。经过训练和信任,他们可以提供宝贵的健康教练和社会支持。现在,全国各地的医院都取决于CHW,这些医院已被证明减少了不必要的急诊就诊和住院。
  • 通过提供食物,咨询和社交联系,使庇护所更加可持续。Simply asking people of color in health-vulnerable households to stay home from work is not the solution. Many people cannot give up their means of support. Subsidized or free contactless delivery of food and other essential services will be critical to enable people to stay home if they are sick or test positive.

大流行对有色人种的影响远远超出了健康问题。从经济上讲,这场危机导致有色人种被搁置或大量。大约有24%的黑人和20%的西班牙裔人报告失业。这些百分比几乎是失业的白人百分比(11%)的两倍。根据美国劳工部的说法,自2015年5月以来,有色人种的失业率与白人的失业率之间的差距最大。


The long-term consequences of COVID-19 for people of color are yet to be determined. But it is clear that the longstanding racial inequities that it has exacerbated are likely to keep growing if they are not addressed. As Black and Hispanic people continue to contract the coronavirus at two to three times the rate that white people do, the disease will spread further in communities of color. This will create a downward spiral of more lockdowns and more job losses, with the attendant problems of inadequate food and housing. And whenever COVID-19 cases surge in the future, they will disproportionately afflict people of color.

COVID-19’s impact on the lives of people of color has been broad, deep, and often misunderstood. It is past the time to do something about it.

作者感谢他们的同事所做的贡献:Venkat Raman在开发本文时的研究,分析和协助;Aradhana Parikh,进行研究和人口分析;和凯尔西·海斯(Kelsey Hayes)进行研究,并有助于确定政策。

桥接Covid-19的种族鸿沟

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